London Borough of Hammersmith and Fulham: Dorothy’s Story

End of life care at home under the Community Response and Reablement team during the COVID-19 pandemic. This case study forms part of our end of life care guide for councils.

Key learning points

  • Strong multi disciplinarily work and communication
  • Good sharing of key information
  • Provision of complex health and social care services to support someone to die in dignity at home
  • Close working with service user and family


In response to the Covid-19 epidemic, Hammersmith and Fulham Council utilised it’s Community Response and Reablement Team (CRRT) to support hospital, community and step-down bed assessments.

A two-week assessment window was applied to ensure quick turnaround assessments to meet demand. The application of the two-week window is an agreed local guideline given the complexity of the cases under its management, not strictly a key performance indicator during the Covid response.

The CRRT work as part of an integrated model under the Community Independence Service; working in partnership with the Rapid Response Service, Community Rehabilitation Team and other health and social care partners.

Best practice principles as set out by the National Institute for Clinical Excellence (NICE) guidelines for managing End of life care (Adults) were followed accordingly in practice.  

These are demonstrated in the case of a local resident ‘Dorothy’ below. The identity of the resident described in the case study has been anonymised for confidentiality reasons.

Dorothy's story

Dorothy was 94 years old when referred to the Hammersmith and Fulham Reablement Service during the Covid-19 pandemic in April 2020.

Dorothy was referred on a Friday afternoon secondary to the care agency declining to continue caring for her secondary to formative COVID diagnosis.

Once the referral was accepted, it was possible to swiftly read the case notes and determine the end of life plan for Dorothy. The notes included analgesic optimisation, Do Not Attempt Resuscitation (DNAR) status and communication history with Dorothy’s family.

The reablement team use two data-bases for the recording of case notes (System 1 and mosaic).

It was therefore possible to quickly determine Dorothy was already being medically-managed by the Rapid Response Team who provided a comprehensive handover to reablement.

The handover included the Consultant Geriatrician offering to complete joint visits and offering telephone advice as required.

Within a two-hour window from referral to assessment, two Occupational Therapists had received a handover and completed an assessment including the following:

Home visit completed to determine manual handling requirements, quality of life goals and recommend care plan for Community Independence Assessor intervention (CIA).

  • Environment: microenvironment planned on ground floor with a appropriate equipments, such as foam high pressure relieving mattress, cantilever table, sliding sheets.
  • Moving and Handling: Determined Assistance of 2 (AO2) persons to roll to left/right side to fit the slide sheet. AO2 to reposition in bed using sliding sheet and bed mechanics. The moving and handling plan incorporated postural management to maximise Dorothy’s positioning to enable her a safe eating / drink position to prevent aspiration considering the carers own positioning in relation to Dorothy. Double handed package of care provided.
  • Eating and drinking: With some persuasion and kind encouragement, Dorothy took a couple of sips of tea from a sip mug during visit, she lacked the respiratory function to suck through a straw. CIA prepared some bite size food / yoghurt offered. Dorothy was reluctant to eat any food even with gentle persuasion.
  • Provided with adapted water bottle on table - OT filled with water and left at on table next to bed within reach. Dorothy left resting in bed in high sitting position with food/drink/telephone within reach. 
  • Handover provided to CIA re: CIA role with supporting care needs. CIAs supported Dorothy QDS with eating/drinking in high sitting in bed when alert and encourage oral intake, change of position in bed with AO2 using sliding sheets, personal care, toileting/continence management in bed with AO2. Recommended that all care needs are met in bed. 
  • Pressure areas checked and concerns escalated as required.
  • Dorothy also suffered from cognitive deficits, however, during more lucid windows, she smiled and understood the care workers and nurses were there to help her. Reassurance was offered regarding her care during every visit.
  • Covid infection control management in the home and disposal of waste plan.

A care plan was written up to ensure all relevant areas of Activities of Daily living were assessed and provided intervention to enable the CIAs and other professionals to provide Dorothy with a dignified death. It also ensured her family she was being cared for with compassion and the highest degree professionalism.

The Rapid Response team remained involved for the provision of analgesia optimisation and the night service visited to provide pain relief at night and turning.

Close daily communication with the Rapid Response team and GP ensured a co-ordinated approach to her care.

Usually the Community Response and Reablement Team’s approach is to determine on-going care needs over a 6-week period. In this scenario the team was instructed to deliver the end of life care. The team have experience of managing end of life resident’s through a holistic multi-disciplinary approach to ensure residents are comfortable and in the least amount of pain as possible before they die.

Dorothy sadly passed away five days after the Community Response and Reablement team assessment. During those five days her family understood she was cared for with kindness and respect.